Home and Community Based Services (HCBS) Provider Credentialing/Re-Credentialing Application

Transcription

1 Home and Community Based Services (HCBS) Provider Credentialing/Re-Credentialing Application GENERAL INFORMATION Corporate (as assigned on W-9) Doing Business As (if applicable) Individual Provider (if applicable) Individual Provider DOB (if applicable) Federal Tax Identification (TIN) Number or Social Security Number ORGANIZATIONAL/INDIVIDUAL PROVIDER TYPE: Adult Day Care Assistive Devices Assisted Living Case Management Chore Services Consumer Directed Attendant Care (CDAC) Counseling Services Emergency Response System Home and Vehicle Modification Home Delivered Meals Home Health Aide Home Maker Services Nursing Services Nutritional Counseling Personal Emergency Response System (PERS) Pest Control Respite Respite Care: Institutional In-Home Senior Companions Specialized Medical Equipment Respite Care: Institutional In-Home Supported Community Living: Residential In-Home Transportation Other 1 Page

2 Copy this page, prior to completing, for additional offices. DEMOGRAPHIC/LOCATION INFORMATION Please indicate the facility s main office, mailing, payment and contact information by completing the appropriate information and checking one or more address type. ADDRESS #1 (choose both, if applicable): Primary Office Mailing Facility/Organization (DBA) Credentialing Contact ADDRESS #2 (choose both, if applicable): Additional Location Mailing Facility/Organization (DBA) Credentialing Contact ADDRESS #3 (choose both, if applicable): Additional Location Mailing Facility/Organization (DBA) Credentialing Contact 2 Page

3 PAYMENT/BILLING INFORMATION Reporting Corporate Tax ID Number Billing Contact Please provide a copy of the W-9 IRS form LICENSURE/CERTIFICATION/ACCREDITATION: State License Number Is the facility/provider a participating Medicare provider? Yes No Is the facility/provider a participating Medicaid provider? Yes No Expiration Date Medicare Number Medicaid Number Business/Retail License Number Expiration Date Is the agency bonded? Yes No Are the caregivers bonded? Yes No If no, please provide proof of insurance for all caregivers Please provide a copy of all licenses and certificates including State or City LIABILITY INSURANCE: Insurance Carrier Policy Number Dollar Amount per Occurrence Dates of Coverage Dollar Amount Aggregate Please provide a copy of your current professional and general liability insurance. OWNERSHIP/MANAGEMENT INFORMATION President/CEO: Chief Financial Officer (CFO): Medical Director: 3 Page

4 OWNERSHIP/MANAGEMENT INFORMATION (continued): Other Managing Employees 1 or Persons with Ownership or Control Interest 2: ATTESTATION QUESTIONNAIRE: If any of the following questions are answered "Yes", please provide details on a separate sheet. 1. Yes No Has the practitioner/facility ever had or currently have pending, any legal actions excluding medical malpractice? 2. Yes No Has the practitioner/facility ever been convicted of a crime, excluding misdemeanors? 3. Yes No Has any government agency ever investigated, suspended, revoked, or taken other action against your license to practice or conduct business? 4. Yes No At any time has any license or certification ever been revoked, denied, or suspended by others or voluntarily given up by the practitioner/facility, or are any actions which may lead to such conclusions now under way? 5. Yes No At any time, has the practitioner/facility been assessed a penalty, conviction or suspension or is the practitioner/facility currently under investigation by the Medicaid or Medicare programs? 6. Yes No At any time, has any third party payors ever revoked, reduced, denied, or suspended your or the facility s participation due to inappropriate utilization management or any quality of care issues? 7. Yes No Has any managing employee or person with an ownership or control interest been excluded from participation in a government program (e.g., Medicare, Medicaid)? W 1 Managing employee" means a general manager, business manager, administrator, director, or other Individual who exercises operational or managerial control over or who directly or indirectly conducts the day-to- day operation of an institution, organization, or agency. 2 A Person with an ownership or control interest" means "a person or corporation that: (a) Has an ownership interest totaling 5 percent or more in a disclosing entity; (b) Has an indirect ownership interest equal to 5 percent or more in a disclosing entity; (c) Has a combination of direct and indirect ownership interests equal to 5 percent or more in a disclosing entity; (d) Owns an interest of 5 percent or more in any mortgage, deed of trust, note, or other obligation secured by a disclosing entity if that interest equals at least 5 percent of the value of the property or assets of a disclosing entity; (e) Is an officer or director of a disclosing entity that is organized as a corporation; or (f) Is a partner in a disclosing entity that is organized as a partnership?" 4 Page

5 STAFFING: Does the facility validate the credentials for licensed practitioners employed or contracted at the facility? Yes No If Yes, indicate how the facility validate the credentials for each practitioner employed or contracted at the facility: Validations are performed internally Validations are outsourced to Other, specify If No, Please explain: EXCLUSION CERTIFICATION: I hereby certify that the on-line exclusion lists for the Health and Human Services, Office of Inspector General (OIG) and General Services Administration (GSA) are checked for all new hires and monthly for existing employees to ensure that no excluded employees work on any jobs related to any Federal health care programs. I also hereby certify that I will remove any employee found on one of the above-referenced lists from any work related to a Federal health care program. The OIG exclusion list can be found at The GSA exclusion list can be found at https: // Authorized Signature for Facility Print Date RELEASE OF INFORMATION, INCLUDING BACKGROUND CHECKS AND AUTHORIZATION: I hereby certify that, to the best of my knowledge, the responses and information contained in this application are complete, accurate and current. I acknowledge that any misstatements or omissions constitute cause for denial of admission to, or summary dismissal from, membership in the AmeriHealth Caritas Iowa provider network. I hereby authorize AmeriHealth Caritas Iowa and its designated agents and representatives to conduct a comprehensive review of the background and credentials of those named on this application. I acknowledge that such review may cause a consumer report and/or an investigative consumer report to be generated. I understand that the scope of the consumer report/ investigative consumer report may include, but is not necessarily limited to the following areas: verification of social security number/tax identification number; credit reports; current and previous residences; employment history; education background; character references; drug testing; civil and criminal history records from any criminal justice agency in any or all federal, state, county jurisdictions; driving records; birth records; and any other public records. I further authorize any individual, company, firm, corporation, or public agency to divulge any and all information, verbal or written, pertaining to me and any others I have presented on this application, to AmeriHealth Caritas Iowa and its agents. I further authorize the complete release of any records or data pertaining to me or others I have presented on this application which the individual, company, firm, corporation, or public agency may have, to include information or data received from other sources. AmeriHealth Caritas Iowa and its designated agents and representatives shall maintain all information received from this authorization in a confidential manner in order to protect the applicant's personal information, including, but not limited to, addresses, social security numbers, and dates of birth. I warrant that I have the authority to sign this authorization, and to thereby authorize the release of information and the performance of a background check, on behalf of all parties named on this application. Signature Print Date 5 Page